urinary retention - oxford medical education · urinary retention causes of urinary retention acute...
Post on 02-May-2019
213 Views
Preview:
TRANSCRIPT
Urinary Retention
Causes of urinary retention
Acute retention o Prostate pathology – benign or malignant
Commonest cause in men is benign prostatic hypertrophy (BPH) o Infection including STI o Phimosis, circumcision o Congenital urethral valves o Clot retention from bleeding source o Urethral strictures o Constipation o Post-operative o Neurological
Cauda equine syndrome, any spinal injury above level of bladder innervation o Medications
Anticholinergic, opiate, antihistamines, cold/flu remedies medication o Alcohol
Chronic retention o Prostate pathology (as above) o Pelvic mass
Benign or malignant o Diabetes o Neurological
MS or other chronic upper motor neurone pathology
History taking in urinary retention
Presenting complaint o Acute retention
Rapid onset suprapubic pain (if painless and acute suspect CNS pathology) Inability to pass urine Possible bleeding Symptoms in keeping with aetiology
e.g. recent dysuria, recent spinal trauma o Chronic
May be as above but more likely: May be asymptomatic Low flow micturition Nocturnal incontinence Palpable painless bladder Clinical signs of chronic renal failure
History of presenting compliant o UTI symptoms o Timing and speed of symptoms o Pain site and severity o Desire to void o Sensation of incomplete voiding o Previous episodes of retention o Recent surgery o Bowels opening
Past medical history o Diabetes o Known prostate disease o Urinary tract tumour/any cancer o Neurological disease e.g. disc prolapse, MS etc o Known anatomical distortion o PMHx will also help determine fitness for future surgery
Medications o Anticholinergics e.g. oxybutynin o TCAs o Opiates o Antihistamines o Cold remedies o Anticoagulants if bleeding
Allergies
Social history o Smoking o Risk factors for malignancy
Focused examination in urinary retention
ABCDE approach to ensure patient safe
Abdominal examination o Is the bladder either visible or percussible
A percussible bladder has at least 150mls in it o Is the bladder palpable?
A palpable bladder has over 200mls in it o Any other abdominal masses palpable? o PR exam
Prostate size and prostate texture (smooth = BPH, craggy = tumour)? Anal tone? Faecal impaction?
Focused neurological examination o Looking for potential spinal lesion, MS (a rare primary presenting complaint in MS), other
neurological condition that can be associated with dysautonomia e.g. Parkinson’s
Initial investigation of urinary retention
Urine dip and MSU
U&Es, FBC and clotting (G&S if frank haematuria)
Blood glucose
Consider PSA if suspicious prostate
Post-catheter o Measure residual volume of bladder o Measure urinary volume removed in first 10-15 minutes to determine true acute retention
versus “acute on chronic” retention o Residual volumes of greater than one litre make patients more likely to fail a trial without
catheter (TWOC) and increase the chances of have recurrent retention
Further investigation of urinary retention
Renal tract USS if very high residual or abnormal renal function on bloods
CT if space occupying lesion suspected
Cystoscopy if urethral/prostate disease suspected
Urodynamic studies if bladder dysfunction suspected
Initial management of acute urinary retention
Acute retention o Catheterise patient
Aseptic technique Consider stat dose of gentamicin (80mg IM if no renal failure) if high risk for UTI
o Post-catheterisation patients may be admitted if: Clot retention Complicated renal colic Frank haematuria Social reasons or lots of co-morbidities Greater than two litres of residual urine
o Post-catheterisation patients may be sent home if they have none of the issues above o On discharge
Urgent follow-up if suspected malignancy, mild haematuria, very abnormal U&Es Non-urgent (usually 2-4 weeks) if uncomplicated UTI, mild prostate pathology. Academic debate regarding how long to leave catheter in: some advocate
immediate removal once drained, others leave in for up to 2 weeks before attempting trial without catheter (TWOC)
In men, give Tamsulosin (400mcgs PO) as a stat dose prior to TWOC. Consider starting long term alpha blockers after discussion with urology.
Suprapubic catheterisation should be discussed with urology if catheterisation fails. o Treat the cause
As above, tamsulosin for BPH Antibiotics for UTI
Trimethoprim or nitrofurantoin as per local trust policy Treatment of constipation
Movicol 3 sachets twice per day, increased dietary fibre More complex causes will need discussion with relevant team
Chronic retention o Less urgency o Catheterise if renal dysfunction or hydronephrosis: be wary of over diuresis requiring
intravascular support and monitor electrolytes o Management is very specific to cause but tend to avoid TWOC until definitive treatment is
available due to poor outcome of TWOC in chronic retention.
References
Kalejaiye, Odunayo, and Mark J. Speakman. "Management of acute and chronic retention in men." European urology supplements 8.6 (2009): 523-529.
Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician 2008; 77: 643-650.
McNeill, S. A., et al. "Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study." Urology 65.1 (2005): 83-89.)
top related